Transcript What is a Wound?

Principles of Wound Care
Ehsan Modirian MD., MPH.
Assistant professor of
Emergency Department
What is a Wound?
Any break in the continuity of body tissue
Examples:
grazes, burns, surgical incisions, stabs,
leg ulcers, decubitus ulcers (pressure
sores)
Stages of Wound Healing




Stage 1 - traumatic inflammation ( 0-3 days)redness, heat, swelling
Stage 2 -destructive phase ( 2-5 days)polymorphs and macrophages clear the
wound of debris and stimulate new growth
Stage 3- the proliferative phase( 3-24 days
increased collagen formation
Stage 4- maturation phase ( 24 days-1 year)
scar tissue decreases granulating tissue gets
stronger and changes from reddish to pale
Closure of Surgical Wounds



Primary closure - first intention
( direct suture- if no tissue loss
Delayed primary closure- usually
when a drain is left in situ.
Secondary intention - wound closes
by a process of contraction and
epithelialisation e.g ulcers and pressure
sores
Factors Influencing Wound Healing







Good blood supply: ( oxygen, nutrients)
Good nutrition:
Rest: skin cells multiply more rapidly
during sleep
Lack of stress: increased levels of adrenaline
and steriods delay healing
Lack of infection:
Age : children heal more rapidly than older
people
Site of wound: face and neck heal more
rapidly
Factors Delaying Wound Healing
General factors
 poor diet
 anaemia
 pulmonary disease
 cardiac insufficiency
 arteriosclerosis
 diabetes mellitus
 smoking







Jaundice
malignant disease
high blood urea
stress
lack of sleep
drug therapy e.g.
steroids and
cytotoxic
radiotherapy
Factors Delaying Wound Healing
Local to patient/wound




skin edges not lined
up
dead tissue in wound
foreign bodies in
wound
tension on wound



infection
irritant material for
suturing
too tight suturing
Complications of wounds







Haemorrhage ( surgical wounds)
Infection
non union
rupture ( dehiscence)
pressure and strain ( coughing vomiting)
over granulation of scar tissue
contractures
Pathophysiology of
Soft-Tissue Injury (1 of 12)

Closed Wounds
– Contusions
• Erythema
• Ecchymosis
– Hematomas
– Crush injuries
Open Wounds
–
–
–
–
–
–
–
Abrasions
Lacerations
Incisions
Punctures
Impaled objects
Avulsions
Amputations
Pathophysiology of
Soft-Tissue Injury (2 of 12)
Soft-Tissue Wounds
Pathophysiology of
Soft-Tissue Injury (3 of 12)

Hemorrhage
– Arterial
– Capillary
– Venous
Pathophysiology of
Soft-Tissue Injury (4 of 12)

Wound Healing
– Hemostasis
• Body’s natural ability to stop bleeding and the ability to
clot blood
• Begins immediately after injury
– Inflammation
• Local biochemical process that attracts WBCs
– Epithelialization
• Migration of epithelial cells over wound surface
Pathophysiology of
Soft-Tissue Injury (5 of 12)

Neovascularization
– New growth of capillaries in response to
healing

Collagen Synthesis
– Fibroblasts: Cells that form collagen
– Collagen: Tough, strong protein that
comprises connective tissue
Pathophysiology of
Soft-Tissue Injury (6 of 12)
The Wound
Healing Process
Pathophysiology of
Soft-Tissue Injury (7 of 12)

Infection
– Most common and most serious complication of open
wounds
– 1:15 wounds seen in ED result in infection
– Delay healing
– Spread to adjacent tissues
– Systemic infection: sepsis
– Presentation
•
•
•
•
Pus: WBCs, cellular debris, and dead bacteria
Lymphangitis: visible red streaks
Fever and malaise
Localized fever
Pathophysiology of
Soft-Tissue Injury (8 of 12)

Infection
– Risk factors
• Host’s health and pre-existing illnesses
– Medications (NSAIDs)
• Wound type and location
• Associated contamination
• Treatment provided
– Infection management
• Antibiotics and keep wound clean
• Gangrene
– Deep space infection of anaerobic bacteria
– Bacterial gas and odor
• Tetanus
– Lockjaw
– Uncommon with the exception of third-world country immigrants
Pathophysiology of
Soft-Tissue Injury (9 of 12)

Other Wound Complications
– Impaired hemostasis
• Medications
– Anticoagulants
» Aspirin
» Warfarin (Coumadin)
» Heparin
» Antifibrinolytics
–
–
–
–
–
Re-bleeding
Delayed healing
Compartment syndrome
Abnormal scar formation
Pressure injuries
Pathophysiology of
Soft-Tissue Injury (10 of 12)

Crush Injury
– Body tissues subjected to severe
compressive forces
– Tamponading of distal tissue
• Buildup of byproducts of metabolism
• “Wood-like” distal tissue
– Associated injury
Pathophysiology of
Soft-Tissue Injury (11 of 12)

Crush Syndrome
– Body is entrapped for >4 hours.
– Crushed muscle tissue becomes necrotic.
• Traumatic rhabdomyolysis
– Skeletal muscle degradation
– Release of toxins
» Myoglobin
» Phosphate
» Potassium
» Lactic acid
» Uric acid
• When tissue is released, toxins move RAPIDLY into
systemic circulation.
– Impacts cardiac function
– Impacts kidney function
Pathophysiology of
Soft-Tissue Injury (12 of 12)

Injection Injury
– High-pressure line bursts
– Injects fluid or other substance into skin
and into subcutaneous tissue
Caring for Wounds
Assess for:
 type of wound
 location of wound
 size of wound
 shape of wound
 level of exudate
 condition of wound bed
 condition of surrounding skin
Caring for Wounds
Recognising inflammation
 redness over area and surrounding
tissue
 swelling
 heat
 pain/ tenderness
 loss of function
Caring for Wounds






cleansing wounds
should it be done?
what should be used?
how should it be done/
types of dressing
who makes the decision
Cleansing wounds: an area where
ritualistic practice predominates
Key questions:
1. Does the wound really need cleaning?
2. What is the safest method that causes
no ill effects and maintains the wound
temperature?
3. What is acceptable to the patient?
Wounds that are clean and healthy do not
require cleaning and should be left alone
Cleansing wounds: Main reasons





Excess exudate and signs of infection
Foreign body contamination ( eg. grit in
a graze)
Presence of devitalised tissue ( slough
or necrotic tissue)
To assess the wound
psychological reasons
Types of Cleansing Fluids
Antiseptics: generally discouraged
now- can be toxic to tissue healing
 Saline solutions: normal saline
sachets commonly used
 Tap water: Why not!!
tip: cleansing fluids should be at body
temperature

Methods of Cleansing



Swabbing: not particularly effective,
mainly redistributes organisms
Bathing: useful for chronic wounds
such as leg ulcers. Take care with
equipment to avoid cross contamination
Irrigation: shower head, waterjug,
syringes - don’t be overzealous
Choice of Dressing
The concept of moist wound healing
Modern dressing technology is based
on the principle that the wound
/dressing interface should be moist
rather than dry.
Common characteristics of wound
dressings




Capable of maintaining
high humidity at wound
site
free of particles and
contaminants]
non toxic / non
allergenic
capable of protecting
the wound from further
trauma






Impermeable to
bacteria
thermally insulating
capable of allowing
gaseous exchange]
able to withstand
infrequent changes
cost effective
long lasting
Patient Factors Influencing the choice
of dressing:






Age
Lifestyle
Medical History
Care environment
Ability to maintain /change own dressing
Competence and willingness of
potential carers
Types of Dressings

Low adherent dressings-Tullegras,Tegapore

Semi permeable films- Opsite, Tegaderm
Hydrocolloids - Comfeel plus, Granuflex
Hydrogels- Intrasite, Sterigel
Alginates- Sorbisan, Kaltostat
Foam dressings- Cavicare, Lyofoam extra
Antimicrobial dressings- Actisorb plus,
Inadine





Minimising Cross Infection



Dressing and cleansing wounds is at
the very minimum a Clean Procedure
and is often an Aseptic Procedures
Thorough hand-washing and use of
gloves are the most effective methods
of preventing contamination of the
wound
If wounds are infected then care must
be taken to prevent cross
contamination